Please complete the following form and answer all questions before arriving for your appointment.
Be sure to include your insurance information.We'll see you soon!
*This information is requested due to Healthcare Reform laws dictated by Congress.
Which family members had the below medical conditions? (father, mother, sibling, etc.)
Your insurance policy is a contract that exists between you and your insurance company. Our relationship is with you, the patient and not the insurance company. If you have questions about your policy, please call the phone number provided on the back of your insurance card. The patient or responsible party is responsible for their bill being paid in full. Please inform us at every visit of any changes to your insurance coverage.
COPAYMENTS: It is a requirement of your insurance company that we collect your co-pay.Payment is required upon checkout.
DEDUCTIBLES & CO-INSURANCE: If you are a NEW OR EXISTING PATIENT a $175 deposit will be collected at the time of the visit which will apply towards your deductible and co-insurance. Any remaining balance after submission to your insurance company is your responsibility. Medicare patients are not required to pay the $175 deposit fee.
SELF-PAY: Full payment is due at time of service. At a minimum, an evaluation and management fee will be charged. Additional procedures/services may be recommended by the doctor but you will be informed of these charges before proceeding with treatment.
REFERRAL: If your insurance plan requires a referral from your primary care doctor, this will be required at the time of your visit. Without a referral available, we may need to reschedule your appointment.
NO SHOW: 24 hours notice is required for cancellation of your appointment and failure to do so will incur a $25 fee. Failure to provide 24 hours notice of a procedural visit will incur a $50 fee.
FMLA/DISABILITY/MEDICAL RECORDS: There is a $25 charge for completion of these forms. There is a $25 fee to obtain a copy of your medical records. There is a charge of $15 for an x-ray disk.
We are pleased to welcome you to our office. New Patients are always appreciated. Our practice has grown as a result of its excellent relationship with our referring doctors and patients. As our patient, please feel free, at any time, to express any concerns or to ask any questions that you may have for the doctor or our staff. In order to assist you in making payment(s) for your podiatric treatment, the following options are listed. Please read them carefully and feel free to discuss them with us.
If you DO NOT have insurance: Payment is due, in full, at the time treatment is provided.
*For your convenience, we accept all major credit/debit cards and cash.
If you have Insurance: The percentage of coverage by your insurance company may be based on your insurance company’s own reduced fee schedule for medical services and may be less than actual charges resulting in lower coverage for you. Carolina Foot & Ankle Specialists has no control over this situation. Lower payment is a direct result of the plan selected by you or your employer. Please be advised that we cannot waive co-payment. We are required by law to collect co-payment.
Commercial Insurance: We will submit your claim to your insurance carrier for you. You are responsible for any deductible or co-payment not covered by your insurance. Once our office has received payment from the insurance company, you will be billed, with 30 day terms, for any amount still owed. You may choose to keep a credit card on file for those balances left to you by your insurance company.
Medicare: This office accepts Medicare assignment.
You have the option to upload images of your Driver's License and/or Government ID and Insurance card if you want but it is not required.
Please ensure you have completed all mandatory fields on this form (indicated with an (*) asterisk next to the field) and please wait until our thank you page loads to ensure the form was successfully submitted otherwise your data will be lost. Please make sure when submitting your form to look out for the confirmation from the office that we have received your form.
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